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CT Scans In ED Soar, But Is That Good Or Bad?

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Here’s perhaps the most startling statistic from a provocative new study about the use of CT in emergency departments: the research “suggests that almost one quarter of the total 71.7 million CTs performed in the United States in 2007 were conducted in the ED.”

Wow.

The study, published online this week in Annals of Emergency Medicine, examined 12 years of National Hospital Ambulatory Medical Care Survey data, from 1996 through 2007. It found that the rate of CT use during emergency-department visits increased by 330 percent, from 3.2 percent of visits in 1996 to 13.9 percent in 2007.

At the same time, the percentage of patients receiving scans who then were admitted to the hospital or transferred to another medical facility decreased sharply, from 26.0 percent in 1996 to 12.1 percent in 2007. Most of the decrease occurred from 1996 through 2003; the percentage has remained basically flat since then.

The authors mention many possible reasons for the increase in CT use, including technological advances that increase CT’s usefulness, increased availability of scanners, “favorable financial reimbursements for imaging procedures,” a decrease in time available for bedside (i.e., non-CT) evaluations, and an increase in defensive medicine.

In an accompanying editorial, Robert L. Wears, MD, of the department of emergency medicine at the University of Florida in Jacksonville, notes:

It seems clear that in a substantial proportion of cases, the CT results allowed what would have otherwise been a hospitalization to be converted to a discharge with outpatient follow-up, a generally beneficial result for both patients and the health care system.

That’s the big issue, isn’t it? Is the increase in ED use of CT good or bad? Has CT allowed emergency personnel to more efficiently discover who’s seriously ill and who’s not? Or have increasing numbers of people who aren’t seriously ill nevertheless been undergoing CT scans, “just to make sure” (or just to fend off lawsuits)?

We don’t know—because we can’t compare outcomes between patients who received CT scans and those who didn’t. We know the percentage of scanned patients who ended up being hospitalized, but not the percentage of unscanned patients who were hospitalized. Did the hospitalization rate among the unscanned also decrease, indicating that more and more of the tougher cases have been getting CT scans—and that the scans have helped sort out, among that problematic population, the serious illnesses and injuries from the not-so-serious?

Or did the hospitalization rate among the unscanned remain the same or even increase, which would suggest that CT use has been expanding into the pool of emergency patients who don’t really need such scans?

Sigh. As always, we require more research.

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